Provider Demographics
NPI:1184489684
Name:HEALTHYLIFE MG CORP
Entity type:Organization
Organization Name:HEALTHYLIFE MG CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MONESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-361-5437
Mailing Address - Street 1:245 BERKSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-4017
Mailing Address - Country:US
Mailing Address - Phone:818-361-5437
Mailing Address - Fax:
Practice Address - Street 1:245 BERKSHIRE AVE
Practice Address - Street 2:
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011-4017
Practice Address - Country:US
Practice Address - Phone:818-361-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-14
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty